Blumenthal Calls For End To Hospital Secrecy

Attorney General Richard Blumenthal called Monday for sweeping changes to the state's "adverse event" reporting law for hospitals, following a story in The Courant on Sunday showing that most reported mishaps are kept secret from the public and closed by the state without an investigation.

Blumenthal said the law should be rewritten to promote greater disclosure of errors and accidents by hospitals and greater transparency to help patients evaluate medical facilities. He also called for an increase in the number of state investigators, as well as statutory authority for his office to seek civil penalties against hospitals that do not comply with the law.

"Clearly, the time has come for ending a culture of secrecy and concealment," Blumenthal said at an afternoon press conference. "This system is broken at its core and must be radically reformed for the sake of consumers and patients across the state of Connecticut. Right now, deaths and severe injuries caused by medical mistakes are undisclosed and unreported, to the detriment of Connecticut patients."

The legislature in 2002 ordered hospitals to report mishaps that killed or seriously injured patients. But a 2004 revision to that law narrowed the types of events that hospitals must report, and promised hospitals confidentiality unless cases were formally investigated. Proponents said that the changes were necessary to get hospitals to fully comply with the law.

Hospitals now report a fraction of the incidents they once revealed, and The Courant cited a number of cases in which patients were killed or seriously injured due to medical mistakes that hospitals said they were not obliged to report under the revised law.

"We clearly ended up with a weaker adverse event reporting system than we had in the first place," said state Rep. Andrew Fleischmann, D- West Hartford, who had supported the 2004 revision. "Now what we have is a lack of response by hospitals in an effort to ignore reporting adverse events."

Even when hospitals do disclose mishaps, the health department closes three-fourths of all reported cases without an investigation — keeping them off limits to the public, The Courant reported. Cases kept secret over the past five years include more than 50 fatalities, more than a dozen sexual assaults and hundreds of serious falls.

"If people are dying in Connecticut hospitals and the Department of Public Health is not investigating, then obviously the law isn't working correctly," Fleischmann said.

Leslie Gianelli, a spokeswoman for the Connecticut Hospital Association, said that ensuring patient safety is "the paramount concern" for every hospital in the state.

"Adverse events are devastating to patients and families, as well as to health care providers. When an adverse event occurs, it is investigated thoroughly by the hospital and reported to the state Department of Public Health, as required by law," she said.

"Hospitals strive to improve each day, collecting data and information about medical errors and putting systems and processes in place to ensure that errors are not repeated," Gianelli said. "Changes to state law implemented since 2004 have made health care safer, and demonstrable improvement has been made in reducing pressure ulcers and falls with injury, among the most frequently reported adverse events."

Blumenthal said that he would meet with legislative leaders to push for changes, and that a key element would be allowing patients to view hospital-by-hospital data on medical mistakes, as consumers in a few states already may do.

Nationwide, about half the states have mandatory adverse event reporting systems, although nearly all, like Connecticut, keep most submissions secret from patients. But for the past five years, Minnesota has issued lengthy reports detailing adverse event figures at each of the state's hospitals. Some facilities have complained about the publicity, but Minnesota health officials earlier this year concluded that "the public reporting aspect of the system has been a catalyst for many changes, and has increased the pace at which best practices are adopted."

In Massachusetts, hospitals release data on the two most common adverse events — pressure ulcers and patient falls — complete with charts comparing each hospital to similar institutions.

Blumenthal said that medical mistakes are the "unfortunate exceptions" to the generally high standard of care offered by the state's hospitals.

"But those failures deserve to be disclosed so that the public may make informed decisions about where they go for care," he said.

To evaluate the state's adverse-event reporting law, The Courant compared cases known to have been reported and investigated against incidents of apparent medical mishaps drawn from death records and lawsuits.

More than 1,200 adverse-event reports have been filed by Connecticut hospitals since the law was changed in 2004, including at least 116 in which patients died. About one in four are investigated, down from half of cases investigated before the law was revised.

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